Nursing evaluation of pediatric preoperative anxiety: a qualitative study

Abstract Objective: to explore and describe how perioperative nurses assess and interpret the child’s behavior before entering the operating room, identifying the strategies they use to reduce anxiety and the proposals for improvements. Method: descriptive qualitative study using semi-structured interviews and participant observation of daily routines. Thematic analysis of data. This study follows the recommended criteria for publication of articles of the qualitative methodology Consolidated Criteria for Reporting Qualitative Research. Results: four topics emerged from the data: a) assessment of anxiety or close communication with the child and their family; b) evaluating what was observed; c) managing anxiety and d) improving the assessment or proposals for improvements in daily practice. Conclusion: nurses assess anxiety in their daily practice through observation using their clinical judgment. The nurse’s experience is decisive for the appropriate assessment of the preoperative anxiety in child. Insufficient time between waiting and entering the operating room, lack of information from child and their parents about the surgical procedure, and parental anxiety make it difficult to assess and properly manage anxiety.


Introduction
Anxiety is a psychological reaction that can be observed in health users who are about to undergo a surgery. A surgical intervention can be very stressful, especially for children and their families, which can cause high levels of preoperative anxiety and postoperative behavioral changes (1) . Recent studies report a prevalence of anxiety of 67-75% in children aged 2-12 years (2)(3) .
Age, personality, developmental status and previous experiences can be triggering factors (2) , and high parental anxiety can also influence the child's anxiety (4) .
It is known that an effective reduction in preoperative anxiety can improve the child's cooperation with the care team (3) , promote a better postoperative response (5) , increase parental satisfaction with the procedure and improve the quality of care (6) . In children, strategies such as the administration of anxiolytic medication, the use of videos, hospital clowns, music therapy and allowing the presence of their parents/ caregivers during anesthetic induction are some of the interventions that aim to reduce anxiety and, thus, promote a more cooperative child during anesthetic induction (7)(8)(9) . However, we cannot only focus on reducing the child's anxiety, as their parents can also be the cause of their children's anxiety, as we have already mentioned. Therefore, strategies such as music, clowns, preopertative programs and educational materials have also been shown to reduce parental anxiety (10) , thereby contributing to a holistic and comprehensive care, which is centered on the children and their family.
Child-and family-centered care can help to humanize the surgical process, which must be centered not only on the child, but also on the family and on the relationship established between them and the health professional. In this approach, the family is an active part of the surgical process and the need for information is increasingly important, parents need information about the process and children must be involved to answer their questions, consider their fears, turn their attention to others and talk to them (11)(12) . A recent study demonstrates how a child-and family-centered program decreases the administration of preoperative sedation, increases the satisfaction of parents and health professionals, and decreases the anxiety of parents and children, in addition to not modifying the surgery times (13) .
On the one hand, it is known that the causes of preoperative anxiety are multiple and its effects can last up to months after the surgical intervention (14) , and on the other hand, it is known that there is a high prevalence of children with preoperative anxiety (15) . Both statements should lead us to think about how we are assessing anxiety and how we are going to minimize anxiety and act accordingly. The assessment of preoperative anxiety in the daily routine is currently performed through the clinical judgment by health professionals (16) . However, we have not found in the literature how health professionals interpret the behaviors and actions of the child before entering the operating room. The objective of this study was to explore and describe how perioperative nurses assess and interpret the child's behavior before entering the operating room, identifying the strategies they use to minimize anxiety and proposals for improvements.

Method Design
A descriptive qualitative study. The qualitative design was considered as the most appropriate to know how the nurses in their daily practice assess the child's preoperative anxiety as it provided the researchers with a rich descriptive content from the perspective of the study subjects (17)(18) . The manuscript has been prepared according to COREQ checklist (Consolidated Criteria For Reporting Qualitative Research) (19) .

Place of study
The study was carried out in the pediatric outpatient surgery unit of a hospital in Barcelona. A third-level University Hospital specialized in the health of children and pregnant women and the first pediatric center in Spain to implement an Outpatient Surgery Unit. The unit has 23 armchairs/individual beds with enough space for two accompanying persons (father/mother) to be with the child during the preparation and after the surgical procedure. Four surgical procedures are performed (two in the morning and two in the afternoon), which can be in the specialty of surgery, ophthalmology, traumatology, otorhinolaryngology, dermatology and dentistry, depending on the surgical schedule.

Study period
Interviews and participant observation were carried from October 2018 to January 2019.

Population
It was proposed the participation of all perioperative nurses from the outpatient surgery unit of the two shifts, about 15 nurses. All nurses in charge of care for children who were admitted to the unit on the day of their surgical intervention. Participants were selected by maximum variation sampling (20) , which ended when data saturation was reached (21) . Two evaluators decided by consensus when the data saturation was reached. The participants were chosen taking into account that they worked in the www.eerp.usp.br/rlae Jerez-Molina C, Lahuerta-Valls L, Fernandez-Villegas V, Santos-Ruiz S. unit and were in charge of care for child and, therefore, for the assessment of anxiety before the surgical intervention; and that there was representation of nurses from both shifts (morning and afternoon). The final sample included nine participants. The first author invited personally and individually all the nurses of the unit to participate. One of the selected nurses who met the eligibility criteria did not agree to be interviewed and/or observed in their daily practice for personal reasons.

Data collection
Semi-structured interviews and participant observation were conducted. The interviews, which lasted about thirty minutes, were conducted in a distractionfree office in the surgical unit by the main author, who worked as a research nurse for a year. The researcher had knowledge in conducting interviews because of previous studies and her academic career. To start the interview, nurses were asked to visualize the moment they first contacted the child and their parents in the waiting room. Once the moment was visualized, a boy or a girl in particular, the first question was introduced: What do you see in the child that makes you think that they have preoperative anxiety? From this first question, the following ones were asked according to the main objective. Thus, questions related to anxiety and how each nurse assessed anxiety, used non-pharmacological strategies to reduce it, and proposed future strategies for its management and assessment were asked ( Figure 1). When do you assess child's anxiety?, How do you assess child's anxiety that makes you think they are nervous? (Child Anxiety Assessment Process) What techniques do you use to reduce preoperative anxiety? On what occasions have you had to reduce parental anxiety? (Difficulties and barriers to reduce anxiety in clinical practice) What do you think should be done to improve the child's anxiety management and how do you think it could be done? (Improvements to reduce children's anxiety)

Figure 1 -Guide for semi-structured interviews
During the interviews, permission was requested for audio recording and field notes were taken, which were used at the end of the interviews to summarize the conversation, clarify some answers and provide additional information. As an additional technique and to increase the quality of the data, participant observation was also performed. It was considered necessary to observe the nurses during their assessment of anxiety, as it is a complex phenomenon to be assessed only through personal interviews (22) . A structured observation was proposed, as it is only possible when the researcher has sufficient information and knowledge about the phenomenon under study, and it was carried out through a event sampling and involved the selection of the events to be observed (23) . Thus, the first contact with the child and their parents and the assessment and management of anxiety by the nurse were observed. The observations were carried out during ten non-consecutive days in both shifts and in different times of the day.

Data analysis
The proposed thematic analysis (24)  The observations recorded in the field diary, the interview transcripts and the notes obtained throughout the study were analyzed by peers.

Criteria of rigor and ethical considerations
The Ethics and Clinical Research Committee of the hospital approved the study (código 15-2018).
All participants were informed about their voluntary participation and signed a consent form.
The recommended reliability criteria were considered to achieve methodological rigor (25) . The participants

Results
The average age of the participating nurses was 36.6 years (Standard deviation 10.9). All of them were women with an average length of service of 9.8 years in the unit.
Sample characteristics are shown in Table 1. Note: All participants were women. Length of service refers to the years the nurse had been working in the Outpatient Surgery Unit and, therefore, assessing the child's preoperative anxiety before entering the operating room.
To illustrate the results, verbatim reports of the interviews or excerpts of the field notes have been chosen.
The names of participants have been replaced by the letter "P" (participant), followed by a number and the letter "O", which means a field diary entry during the observation.
The interviews lasted an average of 30 minutes.
Four main themes emerged from the analyzed data: assessment, evaluation, management of anxiety and proposals for improving anxiety assessment ( Figure 2).  In addition, nurses use words appropriate for the child's cognitive age, avoiding others that can cause more stress, anxiety or fear. Nurses involve parents in this process, instructing and explaining about the anesthetic induction process to them. (….) information, that they will have to breathe inside a mask like the one on airplanes, that they will fall asleep, that we will cure them and when they wake up they will be cured. And they will soon go back to their mom and dad when they are awake again, they will go to a room with a nurse and then they will go back to mom and dad.  When the child is very young, or when it is not possible to understand them due to their age or pathology,

Discussion
The objective of this study was to know how perioperative nurses interpret the child's behavior and how they act accordingly in their daily practice.
In this study, the assessment of child's anxiety before entering the operating room was carried out by the nurses in charge of preoperative care by observing behaviors and actions. Other studies have also reported that the operating room staff are the ones in charge to assess and interpret the child's behavior through clinical judgment (26)(27)(28) . However, such assessment is prone to an important subjective error, as it depends on the skill of the observer to interpret the behaviors and the time available to observe (16) .
Our study suggests that nurses interpret the child's behaviors to assess anxiety and that, if there are doubts about their interpretation, parents are asked. However, the assessment of preoperative anxiety in children by trained personnel has been shown to be more accurate than that reported by parents (28) , although it is not sufficient to detect all children with preoperative anxiety (16) .
In care services with high levels of pressure, such as those in the surgical field, there is a limited time to initiation, and discharge requirements should already be considered within this short preoperative time (29) . Parents need information and health literacy has been shown to reduce anxiety so that they can feel as an active part in the surgical process of their children (30) .
All the actions that the nurse takes to reduce preoperative anxiety, such as providing age-appropriate information and avoiding words that may cause more stress, anxiety or fear, aim at achieving a more cooperative child during anesthesia induction. The implementation of non-pharmacological strategies, such as information about the procedure, playing with the face mask and other distractions, is effective in reducing the child's preoperative anxiety, however, sometimes these strategies are insufficient to help the child cope with the situation (31) .
In these cases, it is necessary to notify the anesthesiologist to administer sedation to the child. However, as in other studies (32) , this work shows that decisions regarding the administration of preoperative sedation are based on personal criteria that lead to non-unified practices.
The results show that there is no protocol or preparation program for parents and children who will undergo outpatient surgery in the hospital studied. These preparation programs, suggested by the nurses studied, have already been pointed out in the literature as one of the aspects that would reduce the levels of anxiety in parents and children on the day of the surgical intervention (33) and would save time in the surgical process (34) .
Training the use of the face mask at home and teaching distraction techniques to parents are two components of the preoperative preparation program observed as the most effective in keeping the child's anxiety stable throughout all phases of the preoperative period on the day of the surgical intervention (35) . In addition, the child who is aware of the process is a www.eerp.usp.br/rlae 7 Jerez-Molina C, Lahuerta-Valls L, Fernandez-Villegas V, Santos-Ruiz S.
facilitator and it is beneficial for the health professional, as the child can actively participate if they are informed (36) .

Likewise, when the parents are informed about what is
going to happen and about what is expected of them as parents, they feel involved in the care of their child and not as bystanders, as for example, during anesthetic induction (37) . Preoperative preparation of children and their parents could reduce the levels of anxiety, improve coping, and promote postoperative recovery (38) . The nurses in this study have stated that children and parents should be prepared before going to the operating room (39) .
Although we currently have non-pharmacological strategies to reduce pediatric preoperative anxiety, we still have limitations (14) . As the surgical time to prepare children and parents is very short on the day of the surgical intervention, other strategies not related to therapeutic play could be proposed, since these have already proven to be effective (40) . Thus, these strategies would be supplemented with other ones, such as information on the process by team trained in emotional care (41) and reinforced by means of written information (42) .
One of the limitations of this study is that the assessment was performed only in a pediatric outpatient Lack of time is the main barrier for strategies such as active listening, therapeutic play and age-appropriate information to reduce children's anxiety before surgical intervention. It would be up to the facilitator to guide and train parents before their children's surgical intervention so that they can be an active part of the process, as well as provide children with age-appropriate information through the implementation of preoperative preparation programs and parent training throughout the surgical process so that they can be an active part in this process.
Although there is still a need to assess preoperative anxiety through the use of validated instruments that aim to unify the care and strategies based on the objective assessment of preoperative anxiety, nurses consider that perioperative care should focus on the child and their family, and therefore, the assessment of anxiety should be performed considering the child-parents and childnurse relationships.
Based on the results found, future studies are recommended to assess whether the preoperative information provided by a team trained in pediatric emotional care reduces the child's anxiety on the day of the surgical intervention, as well as to study whether the variation and difficulty in the assessment of preoperative anxiety in daily practice is homogenized by using preoperative anxiety assessment protocols that were unified by all health professionals involved in the perioperative process.